Thursday, May 19, 2016

The U.S. Department of Health & Human Services ("HHS") dropped the ball when it recently defined discrimination in plan benefit design under the Affordable Care Act ("ACA"); that statement is plainly put because it is true! Absent clearer guidelines, HHS basically issued a green light for insurance carriers to potentially discriminate against people living with chronic illnesses, including HIV/AIDS. Stakeholder groups have cried foul over the regulations, characterizing them as weak.

The ACA's Section 1557 is the nondiscrimination provision of the law. It law prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. Section 1557 builds on long-standing and familiar Federal civil rights laws: Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975.[1]

Photo Source: Class Action News

The "I Am Essential" coalition sent a letter to HHS signed by 197 organizations on the proposed rule. The letter outlined numerous concerns. Among them:[2]

placing all or nearly all medications to treat a certain condition on the highest cost-sharing tier;

not covering certain medications or not following treatment guidelines;

There is plenty of evidence to suggest that marketplace plans are already engaged in discriminatory practices, which in many cases have adversely impacted patients living with HIV/AIDS. High deductibles, high co-insurance, and high co-payments are a few tactics being used by insurance carriers to shift the cost of care to patients living with chronic illnesses. To read last week's blog on this trend, CLICK HERE.

HHS, however, did leave the door open to review alleged discrimination on a case-by-case basis. Albeit welcome news, there has to be a better approach to potential barriers that may arise.

Carl Schmid, Deputy Executive Director, The AIDS Institute, characterized some of the concerns, "We are disappointed that HHS did not do a better job at specifically defining discrimination in plan benefit design. Despite the many benefits of the ACA and its prohibition on denying coverage to beneficiaries with a pre-existing condition, some insurance plans are finding ways to discriminate against patients, particularly those with chronic and serious health conditions. Those practices should be defined and clearly prohibited. However, we are pleased that HHS reiterated they will review plans for discriminatory practices on a case-by-case basis through their enforcement activities, and identified a number of examples of possible discriminatory plan design. We urge the Administration to rigorously use their oversight and enforcement tools."[3]

Even the pharmaceutical industry's trade association expressed caution over the regulations issued by HHS, acknowledging that they neglect to define discrimination. The Catalyst, which is the Pharmaceutical Research and Manufacturers of America's (PhRMA) blog, said:

"Protecting patients from discriminatory benefits is particularly important when it comes to plan formularies. For many patients with chronic conditions, it is relatively easy to predict their prescription drug needs. This means plans may be able to discourage enrollment by certain higher cost individuals simply by not covering the medicines they need or placing them on a high formulary tier. Unfortunately, we have seen many marketplace plans placing all medicines for certain conditions on the specialty tier or on a tier with coinsurance above 40 percent. In some cases, this is even happening in classes where generics are available. This leaves patients with no lower cost alternative and goes against the very nature of insurance by punishing individuals who happen to need a particular class of medicine."[4]

It is crucial that the public health community continue to monitor these glitches with the Affordable Care Act and collaborate on solutions to better assist patients living with chronic illnesses. Left unchecked, insurance carriers have demonstrated a history of pushing the envelope when it comes to discriminating against HIV/AIDS.
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Friday, May 13, 2016

On April 25th, Avalere Health published a comprehensive study on marketplace exchange plan formularies offered under the Affordable Care Act ("ACA"); it includes a cross-condition analysis addressing formulary coverage, cost sharing and access. The study, which was prepared for the Pharmaceutical Research and Manufacturers of America®(PhRMA), suggests that certain disease classes -- including HIV/AIDS -- experience bias under many of the plans.

Most of the law’s major provisions were phased in by January 2014, with other provisions phased in by 2020. The ACA has numerous implications generally on the United State’s health care delivery system, but more specifically on the access to healthcare afforded to people living with HIV/AIDS, as well Viral Hepatitis. What’s more, ongoing Medicaid expansion and the implementation of insurance exchanges will also impact nearly all health care providers, as well as their patients.

According to the Avalere study, formulary access for patients with HIV/AIDS has expanded though other barriers remain. The study included the following summary:[1]

In high-enrollment states, the average exchange plan covers at least 43 of 51 HIV/AIDS medications

Single-source products in the therapeutic area appear on formulary at least 65% of the time in all states other than Utah, which has coverage 25% of the time

Utilization Management for HIV Classes:

Exchange plans have continued to reduce their use of UM for HIV/AIDS medications. Now, exchange plans use UM less frequently than employer plans for these medicines

Tiering and Cost Sharing for Key HIV Classes:

Preferred placement has increased for HIV/AIDS medications in 2016 exchange plans, though employer plans still use the specialty tier far less often than exchange plans do. And, a portion of plans continue to place all HIV drugs on the specialty tier

Copays are common across HIV classes, with an average copayment of $66. When used, coinsurance is 35% on average

Photo Source: PhRMA

One of the more alarming findings demonstrates that many of the marketplace exchange plans require high cost sharing, which could be discriminatory. In 2016, about 1 in 10 health plans are placing all HIV medicines in certain classes on the specialty tier.[2]

This discriminatory practice took center stage in 2014, when four insurance carriers were sued by the National Health Law Program (NHeLP) and the AIDS Institute. The complaint charged “inordinately high co-payments and co-insurance for medications used in the treatment of HIV and AIDS" against Coventry Health Care Inc., Cigna Corp., Humana Inc. and Preferred Medical.[3]

Additional findings include:[4]

In states with high exchange enrollment, average plans cover at least 43 of 51 drugs.

Across classes, plans cover HIV/AIDS innovators at least 76% of the time, except Utah.

In 2016, exchange plans use Prior Authorization for HIV meds less often than before, but still more than employer plans.

Exchange plans’ placement of HIV/AIDS drugs on the preferred tier rises to more than half of the time in 2016.

Copays are more common than coinsurance, though when used, coinsurance averages 35%.

Exchanges have lower coverage for STRs than for other single-source NTRIs.

Ten percent or fewer plans in 44 states and D.C. require coinsurance above 30% for all covered NNRTIs.

New Jersey has the highest proportion of plans requiring coinsurance of 30% or more for all covered NRTIs.

Alaska, Minnesota, and New Jersey have the highest percentage of plans requiring coinsurance above 30% for all protease inhibitors.

Coinsurance above 30% for all covered therapies in HIV-other class is most common among plans in Alaska, New Jersey, Utah.

The ACA has largely benefited patients living with HIV/AIDS by expanding access to care, and lowering the ranks of the uninsured and under-insured. That said, despite some marked improvements in many exchange plans there remain ongoing barriers facing too many patients. Among them, higher deductibles, co-payments and co-insurance.

Friday, May 6, 2016

What is the greatest unmet need for people living with HIV (PLWH)? Medical care and medications? Transportation? Food and nutritional needs? Many, many surveys and research findings provide very a different answer: housing. When you think about it, the need for safe, decent, affordable housing is a no brainer. How can you and your family possibly succeed in medical care or in the workplace or any place else without a place to lay your head, to keep your meds, and to protect your children? I would go so far as to say housing = healthcare!
According to the National Low Income Housing Coalition’s 2015 Out of Reach Report, not a single state in our nation offers a one-room apartment that a person working full time and making minimum wage can afford. In fact, federal minimum wage has not increased since 2009 while rents have risen in almost all metropolitan areas. For PLWH, the need for housing assistance is far too commonplace. According to the National AIDS Housing Coalition, at any given time about 50% of 1.2 million PLWH in our country experience homelessness or housing instability. Additionally, research indicates that people who are unstably housed or homeless have HIV rates up to 16 times as high as persons in stable housing. Unfortunately the need substantially outstrips the resources. But here’s the bottom line: housing for PLWH improves medical outcomes, reduces new transmissions through a reduction in risky behaviors, and provides cost savings. So much research exists to confirm these results that AIDS and Behavior in 2007 dedicated an entire issue to illustrate the findings.

Photo Source: National Low Income Housing Coalition

The only HIV-specific funding source from the U. S. Department of Housing and Urban Development (HUD) is the legislation known as Housing Opportunities for Persons with AIDS (HOPWA). Although HOPWA is relatively small within the HUD portfolio at about $335 million, the program has been extraordinarily effective and well rated, enjoying bipartisan support. Research from New York City shows that clients assisted by HOPWA collectively have a viral load suppression of about 73%, more than double the national average of about 30%. HOPWA was created in 1992 to address the housing and service needs of PLWH. Currently, however, the statutory funding distribution methodology is based on cumulative AIDS cases and counts more deceased cases (over 650,000) than living cases. On top of the formula distribution (don’t forget: based on deceased people and AIDS only), urban areas with higher-than-national averages also receive 25% of the formula funds as a bonus, based on three-year AIDS incidence, providing disproportionate funding to these jurisdictions. As a result of this antiquated methodology, I once saw the Director of the Office of HIV/AIDS Housing, David Vos, tell a group of advocates that the per-case funding can range from $200 to $10,000. Should funding this important really be based on deceased cases and distributed in a roller coaster ride of injustice?

The National AIDS Housing Coalition (NAHC) and many other HIV organizations have been advocating for an update to this formula distribution for many years in an effort to distribute the resources in a way that better reflects the current HIV epidemic. Both the Obama Administration and HUD are working in concert with NAHC and elected officials to promote modernization that would include the following changes:

A shift from cumulative AIDS to living HIV/AIDS, a change that occurred within the Ryan White legislation in 2009;

The inclusion of an area’s housing costs and poverty rates as formula factors; and

A gradual implementation over a five-year period to include a provision to cap annual losses at 5% and gains at 10% (U. S. Congress, House, H.R. 3700 and H. R. 4707; and Senate, S. 2668).

These changes would provide substantial additional resources to many rural areas, small to mid-sized cities, and states, based on the jurisdiction’s burden of cases, Fair Market Rent, and poverty index.

Although funding to support stable housing may never fully meet the needs of PLWH, advocates must continue to elevate this topic and to integrate housing needs into other HIV resources, such and the Ryan White HIV/AIDS Program and other programs within the Centers for Medicare and Medicaid Services. Innovative collaborations between branches of government and funding opportunities that combine structural interventions, such as housing, with other medical and supportive services could only help to alleviate barriers to good health caused by a lack of housing for PLWH.

AIDS Alabama provides an innovative approach to the use of our state HOPWA funds. Through partnerships with all of the AIDS Service Organizations, AIDS Alabama makes HOPWA rental assistance and supportive services available in all 67 counties of the state. We believe that housing is a human right and that people in need should have access to assistance no matter what zip code they call home. But we don’t stop with HOPWA! Our agency has continued to develop HIV-specific housing across the state and in the Birmingham area that we can make affordable to our clients. AIDS Alabama is extremely active in our local Continuum of Care to serve the area’s homeless population. We believe in HUD’s Housing First model, which gets people into safe housing and then allows us to assess and address other needs that will keep our new residents healthy and independent. Through these homeless funds we offer substance use treatment and mental health services for our residents. We are able to access Shelter Plus Care vouchers, which work like Section 8 assistance for people with disabilities. We work especially hard to serve the chronically homeless and to get them into care. In order to do that, we provide about 20,000 legs of transportation to medical appointments each year. We are extremely excited about our newest project that will begin in October 2016, which will target young, homeless LGBTQ populations. And, of course, case management services are available to all of our clients. Navigating the worlds of health care, housing, and insurance is hard for anyone!

At AIDS Alabama our employees, residents, and clients living with HIV play a critical role in making sure that we remember who we serve and that we serve in the most efficient and helpful way possible. Persons living with HIV must have meaningful involvement in shaping everything that we do as an agency. Hopefully one day soon we can end this epidemic in the United States. Until that happy day we will work together toward this goal…and make sure that everyone has a place to call home while we do this work!

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Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.